RESEARCH ARTICLES

Sexual practices of nursing undergraduates and prevention of sexually transmitted diseases

Haisa Borges d'Amaral^I; Laís de Andrade Rosa^II; Raquel de Oliveira Wilken^III; Thelma Spindola^IV; Maria Regina Richerte Araujo Pimentel^V;Luiz Eduardo da Motta Ferreira^VI

^I Nurse. Graduate student in midwifery residence by the Federal University Fluminense. Nursing School of the University of Rio de Janeiro State. Brazil. E-mail: haisa.borges@gmail.com
^II Nurse. Graduate student in medical-surgical nursing by the Federal University of Rio de Janeiro State. Nursing School of the University of Rio de Janeiro State. Brazil. E-mail: laisandraderosa@gmail.com
^III Nurse. Graduated from Nursing School of the University of Rio de Janeiro State. Brazil. E-mail: raqueldeoliveirawilken@hotmail.com
^IV Nurse. Ph.D. in Nursing. Associate Professor at the Department of Nursing Fundamentals. Nursing School of the University of Rio de Janeiro State. Brazil. E-mail: tspindola.uerj@gmail.com
^V Nurse. Ph.D. student in Nursing. Assistant Professor of the Department of Nursing Fundamentals of the Nursing School. University of Rio de Janeiro State. Brazil. E-mail: mariaregina.pimentel85@gmail.com
^VI Doctor. Master degree in Cardiology. Adjunct Professor of the Medicine and Surgery School at the Federal University of Rio de Janeiro State. Brazil. E-mail: luizmotta@predialnet.com.br
^VII Member of the research entitled: The sexual practices of nursing graduates and the prevention of sexually transmitted diseases presented as prerequisite for approval in Graduate Nursing, at the University of Rio de Janeiro State, in 2014.

DOI: http://dx.doi.org/10.12957/reuerj.2015.16823

ABSTRACT

This quantitative, descriptive study drew on the database of the research Evaluating university students' knowledge, practices and beliefs in relation to sexually transmitted diseases in order to identify the sexual practices of nursing undergraduates, their vulnerability to STDs, and the attitudes and practices they deploy to prevent them. A questionnaire was applied to a sample of 89 undergraduate nursing students at a public university Rio de Janeiro City in 2013-2014. The results showed that these young people's use of condoms is not continuous, making them vulnerable to contracting sexually transmitted diseases. Actions that contribute to these young people's health education, including encouragement for their adopting safe sex practices, help to prevent the occurrence of sexually transmitted diseases and should be promoted.

Keywords: Sexual practices; university students; sexually transmitted diseases; prevention.

INTRODUCTION

The objective of this study is the sexual practices of young people and the prevention of sexually transmitted diseases^VII. The discovery and sexual initiation of young people associated with the practice of sex in an unsafe way, contribute to become part of the most vulnerable group in contracting diseases, especially those transmitted by sexual contact. The lack of means of prevention, ways of contagion or simply risk behavior adoption are situations to be investigated since they reflect the incidence of sexually transmitted infections (STIs) among young people. The Acquired Immune Deficiency Syndrome (AIDS) are among the diseases that are associated with the practice of unprotected sex, considered as a milestone in the global epidemiology accounting for significant changes in health and bringing discussions about sexual behaviors, beliefs, values and myths associated with sexuality^1,2.

Sexuality of a social group is determined according to values, concepts and norms of the society to which they belong, according to the historical moment that will determine the right or wrong, appropriate or inappropriate in accordance with current standards. In addition to the sexual practices, desire, affection, pleasure and fantasies are part of the sexuality³.

Ministry of Health data show that from 2000 to 2006 there were 19,793 AIDS cases in young people aged between 13 and 24 years old in Brazil, accounting for 80% of reported cases. According to the STD/AIDS Epidemiological Bulletin, there are about 709,477 AIDS cases identified in Brazil from 1980 to June 2013. In Rio de Janeiro in the last five years, there has been an increase in the number of reported cases of AIDS among young people from 15 to 24 years old, from 16.7% in 2008 to 19.3% at 2013^4,5.

Some factors can be identified as responsible for the contamination rates, including misinformation about the subject and the lack of family dialogue to guide young people about sexuality. Parents find it difficult to talk about sexuality issues with their children, not only by constraint, but also for fear that frank and open dialogue can indicate to teenagers who are ready to begin sexual life. Authors^6,7 claim that young people take on risk behavior and become vulnerable to have sex without the adoption of condoms for fear of losing a partner.

The increase in AIDS cases among young people has been significant in recent years. This may be associated with the onset of sexual activity, around 15-16 years old (detected by the National Demographic and Health - PNDS 2006), and also to have occurred from 1998 a reversal in the sex ratio, occurring AIDS in this age group. In the period of 2000 to 2005 there was a reversal of the sex ratio of the number of AIDS cases in the age group from 15 to 24 years old (0.9 cases in men for each case in women), in 2012 the case detection rate AIDS in males was 15.1/100,000 and 8.6 in women. In this context, it is predominant to professionals and health services pay attention to the specific health needs and demands of this population^4,5.

This study is relevant considering the vulnerability of young people to sexually transmitted diseases, according to the epidemiological bulletin of the Ministry of Health, and economic and social issues should be observed that determine the need for more specific and comprehensive attention to this group.

The research aims to identify the sexual practices of graduate students in nursing, vulnerability and practices adopted by young people to prevent sexually transmitted diseases.

LITERATURE REVIEW

In the maturation process of the human beings, individuals experience the different stages of life and their peculiar characteristics. Adolescence is a gradual change phase from childhood to adulthood, and professionals who are dedicated to the care of young people have studied it. Considering this phase presents different chronological limits according to the interpretation of the various official bodies, the defining the Statute of Youth was adopted in this research, set up by the presidency of the republic in 2013, which considers young people aged between 15 and 29 years old. In this document, it was agreed that to avoid conflict situations for young people in the age group of 15 to 18 years old will prevail Law 8069 of July 13, 1990 - Statute of Children and Adolescent^4,8.

Vulnerability is understood as the chance of exposure of people to illness, this concept widely used in planning and preparation of STD and AIDS control strategies. The vulnerability of different population groups can only be understood when it is clear the relevance of a wide range of aspects that can be grouped into three levels, which are: individual, institutional and social⁹. Therefore vulnerability is understood as a dynamic state of weakness and sensibilities in different dimensions, resulting from the interference of various factors, symbols and representations¹⁰.

In this context, it is known that the discovery and sexual initiation occurs usually in adolescence and that this stage of life the vulnerability is related to the emotional and psychological characteristics, the desire to experience new things, and this fact associated with immunity feeling perceived by many young people favors to become more susceptible to contracting diseases through the practice of insecure sex^7,11.

The environment in which the teenager is inserted is another factor that influences their attitudes and sometimes they take risky behaviors mainly involving the use of drugs, tobacco, alcohol and sexual activities. By analyzing the vulnerability of young people to STD, there is the association between alcohol/drugs and sexual activity, considering that no matter how small the amount of drug used, it can cause changes in perception and lead young people to make bad decisions or conduct risky sex, being vulnerable to unplanned pregnancy and sexually transmitted diseases¹².

A research about knowledge, attitudes and practices in the Brazilian population (PCAP) published by the Ministry of Health in 2011 shows that 77.6% of young people from 15 to 24 years old have active sexual activity. Only 35% of young people surveyed in this age group reported regular use of condoms independent of their partnership, showing that Health Education for STD prevention should be continuous and more deep¹³.

Ao mesmo tempo em que as práticas educativas são pouco abordadas, a liberação de costumes e a erotização da mídia vêm estimulando uma iniciação sexual cada vez mais precoce, o que também pode aumentar as chances do jovem contrair DST. Nota-se que quanto mais jovem é o indivíduo menor é o nível de informação, tornando-o vulnerável para contrair doenças transmitidas pelo sexo. De acordo com dados do Boletim epidemiológico no período de 1980-2012 há registro da ocorrência de Aids em jovens de ambos os sexos nos grupos etários de 15-19 anos e de 20-24 anos totalizando 12.246 casos e 57.429 respectivamente. As tendências apresentadas atualmente pela epidemia evidenciam a heterossexualização, feminização, interiorização e pauperização^4,5.

While the educational practices are poorly addressed, custom freedom and media's sexualization have been stimulating a sexual initiation increasingly early, which can also increase the chances of STDs in young people. It is noted that the younger the individual, the smaller the level of information, becoming vulnerable to contracting diseases transmitted by sex. According to the epidemiological bulletin data in the period of 1980-2012, there are records of the occurrence of AIDS among young people of both sexes in the age groups of 15-19 years old and 20-24 years old totaling 12,246 cases and 57,429 respectively. Trends currently presented by the epidemic showed the heterosexuals and women, internalization and pauperization 4.5.

Therefore, health education has an important role in this scenario considering health promotion for the development of autonomy and responsibility of people and communities with their health. It is a critical social practice and transforming widely used for the prevention of STD/AIDS. Even today, there is a taboo in the dialogue between parents and children about sex and sexuality. Some health professionals also demonstrate unpreparedness to engage the subject with adolescents^7,9,14.

The nurse has an important role as health educator and performs a practice that converges to the sociocultural context of adolescents. In educational activities in a warm atmosphere with young people, there are doubts with an involvement, exchanging of information and experiences resulting in the construction of collective knowledge. This practice has proven efficient for learning about issues related to sexuality and STD prevention^11,15.

METHODOLOGY

Descriptive and quantitative study conducted with data from the research Assessing the knowledge, practices and beliefs of university students regarding to sexually transmitted diseases, coordinated by Professor Dr. Thelma Spindola.

The study was conducted in 2013/2014 in a public university located in the city of Rio de Janeiro, together with graduate students in nursing, over 18 years old, enrolled in the Nursing School.

A structured questionnaire was applied with 50 questions (47 closed and 03 open), to students who attended from the 1^st to the 9^th academic year. To compose the study, a stratified sample of intentional type was used, having selected 40% of students in each class enrolled in the institution. Initially, there were 17 instruments applied in each class, totaling 153 questionnaires. After the loss of 10 questionnaires (without devolution) and the application of the exclusion criteria: under 18 years old questionnaires completed incongruously, there were 08 instruments excluded. At the end, there were 135 valid questionnaires and data were stored in Microsoft Excel 2010 software, and analyzed using descriptive statistics. To meet the objectives of this study, questionnaires of participants sexually active were only used totaling 89 instruments. From data collection instrument applied, there were 16 variables analyzed related to socio-demographic characteristics and sexual behavior of participants.

The largest study was approved by the Research Ethics Committee (COEP) of the State University of Rio de Janeiro with the opinion Number 063/2012.

RESULTS AND DISCUSSION

Sociodemographic characteristics

Students investigated have sociodemographic characteristics highlighted in Table 1.

TABLE 1: Sociodemographic characterization of university students. Rio de Janeiro, 2013. (N=89)

The results show that most university students were female - 76 (85.4%). Higher Education Census data from 2012 collected by the National Institute of Educational Studies Teixeira (INEP), show that the highest enrollment rates in higher education are recorded in female people¹⁶. The increase in women entering the higher education can be related to increased female participation in the labor market. According to the Brazilian Institute of Geography and Statistics - IBGE - the distribution of the employed population in the country is represented by 63.9% of women and 61.0% of men aged 25-49 years old ¹⁷. Then, the framework of active economic society in the country has been changing gradually, with the participation increasingly present of women in the labor market, occupying spaces where there was predominance of the male group.

Considering the investigated group were nursing students, it is observed that this profile is associated with the profession of nursing, predominantly female area, due to the involvement of women in the act of caring, and reproduced today in nursing¹⁸. In the age group, 54 (60.7%) are between 18 and 21 years old. These findings are in line with the last Census of Higher Education (2011), being evident that the proportion of young people aged 18 to 24 become from 22.9% to 47.1% at the end of last century to 2011, noting the increasing number of young people to higher education in all regions of the country¹⁹. In this period of youth, it is known that young people are at the height of their active sex life, since the average age of sexual initiation of Brazilians are around 15 years old²⁰.

Therefore, entering in the university is a time for celebration and fun with friends and often, there is a greater exposure to alcohol and drugs associated with sexual practices resulting in a decrease use of condoms, considering these substances change the sense-perception of individuals²¹.

With regard to religion, 35 (39.3%) of respondents declared to be Catholics and 19 (21.3%) Evangelicals. Religion plays a very important role for people because they can influence how young people relate to the socio-affective level. Protestantism and Catholicism are Christian religions and since the beginning usually treat sex and sexuality in a repressive way, which can cause difficulty to address these issues and influence the sexual practice of young people²². Depending on the social changes of current time, however, it is believed that even these spaces may be occurring changes that favor dialogue and reflection.

As for the marital status of the participants, 45 (50.6%) stated that were only dating and 30 (33.7%) have no boyfriend. Dating is a social and emotional relationship important for the development of the human being. That time, it is often associated with the onset of sexual activity that usually occurs in adolescence²³. It is during adolescence that many young people experience the onset of sexual activity, and this time do not always adopt the practice of unsafe sex, being vulnerable to contracting a STD²². The stated marital status is consistent with the age of the study participants, considering that young people tend to look for more serious relationships when older ages.

Sexual practices

The results about condom use according to the type of affective relationships of nursing students can be seen in Table 2.

TABLE 2: Distribution of students according to use of condom in the last 12 months, and type of relationship. Rio de Janeiro, 2013.

Study participants reported that in the last 12 months, 19 (21.36%) had a relationship with casual partners using condom. It is known, nowadays the love lives of young people has undergone changes in behavior patterns. Before settling a dating, there is a prior relationship with casual partners contributing to the increased number of people with whom the youth can relate sexually. In these relationships, the practice of condom use does not continue, it may result in damage to the health of this group and become a public health problem²⁴.

Out of the total number of students (89) who were sexually active, 46 (51.7%) had sex with a steady partner in the last 12 months and used condoms in these relationships; 34 (38.2%) did not use it and 9 (10.1%) did not report it. Although 46 (51.7%) of participants have informed the adoption of condoms, it is noted that the other 43 young people (48.3%) have proven resistant to incorporate this practice in their sexual activities. A study found that young people are using condoms according to the type of relationship (fixed or casual partner) and partner´s appearance, with or without promiscuity, employ the condom as contraception and not to prevent STDs²⁵.

Although the research participants use condoms with steady partners, is still significant number of young people who did not use it, 34 (38.2%). The non-adoption of condoms in sexual contacts may be related to the fact that stable relationship involve trust in the partner and use that feeling as a form of prevention. Moreover, in these relationships there is a greater use of the contraceptive pill, demonstrating a greater concern for young people to avoid an unwanted pregnancy than use condoms to prevent sexually transmitted diseases²⁶.

Because it is a study where most participants are women and not using condoms, this may be related to the difficulty for women to negotiate condom use with fear of losing or upsetting the partner or spend a vision of being experient²⁷. A study conducted with women over 18 years old at a university in the city of Rio de Janeiro found some lack the courage to propose the use of condoms, fearing the reaction of the partner, since the request for the use of condoms can generate distrust in her partner²⁸.

The practice of safe sex among students is expressed by the results in Table 3.

TABLE 3: Sexual practices of university students. Rio de Janeiro, 2013.

When discussing the constant use of condoms, there is the subjectivity involved in this practice. The survey results show that 25 (28%) students do not always practice safe sex and have had more than one sexual partner in life. Several factors may be associated with this behavior and contribute to this group to be more vulnerable to STD and AIDS. Several factors that lead an individual to not use a condom can be listed as: negative attitudes towards condom use, decreased claim sensitivity and interference with naturalness and spontaneity of the sexual act, the use of alcohol and drugs, forgetting to use it and the difficulty in negotiating the use of condom^18,29,30. When discussing the female condom use, no use it has performed expressively. A study found that young people have difficulties in using and handling the female condom, and its cost is high when compared to male condoms³¹. However, it should be noted that condoms (male and female) are distributed for free in basic health units in the city of Rio de Janeiro.

A research held in Fortaleza, in a public institution of higher education in 2010, indicates that young people are more vulnerable to epidemics. In university students, vulnerability may be associated that because they have entered the higher education, they believe they have enough knowledge, and do not realize their exposure to STDs. When there is an association between sexual practices and the prevention of diseases and disorders, this population appears to be more interested in preventing an unwanted pregnancy to avoid STDs³².

There are also subjective aspects involved in the sexual practices of individuals as well as their own sexuality. Sexuality is associated with values and social norms that are tied to emotions and instincts. These aspects should be valued, but often are not controlled/rationalized at the time of sexual intercourse. The continued use of condoms, however, is a practice that needs a stimulus to become natural³¹.

With regard to sexual and reproductive health of young people, the nurse plays an important role in education activities in adolescent health, stimulating self-care, answering questions and promoting integrity among the sectors of education and health, contributing to reducing STD/ AIDS vulnerability in this group³³. Thus, it is important for nurses to realize the health education approach to act in a critical and transformative education, covering the biopsychosocial needs of individuals and collective actions³⁴.

It is appropriate to point out that, in the exercise of their functions, the nurses play the role of educators and continually need to update their knowledge, process and/or expand their professional practice through continuous education³⁵. In this context, they can work on projects in the schools participating in the health education of young people, such as the Health Program in Schools (PSE) that assists sexual orientation, STD prevention and teen pregnancy public network¹¹.

CONCLUSION

The findings of the study show that nursing graduates, like other young people, are related to staedy and casual partners. They adopt the male condom in most sexual intercourse. However, there is a significant proportion (over one third) who does not practice sex ever safe, being vulnerable to STDs.

Considering that the study was carried out with nursing students, with major predominance of women, it is evident the gender ratio in negotiating condom use with their partner, and that women generally find it difficult to negotiate the practice for fear of losing a partner. Among young people who had relationships with casual partners, the fifth part reported having used a condom. However, considering that about half of the sample does not practice sex ever safe, this scenario is very worrying, especially if there is association between alcohol and drugs with sexual activity.

The research achieved the objectives as identified sexual practices of nursing graduates and the vulnerability of these young people to sexually transmitted diseases.

The number of participants can be considered a limitation of the investigation, but the results show the importance of research to be replicated in other areas, including students from other areas of knowledge for a better assessment of the issue.

These findings suggest that although the participants are students from the health area students, their sexual practices are similar to other young people and not necessarily are associated with knowledge about the spread of STDs. It is then recognized to carry out actions that stimulate reflection of young people for informed decision-making regarding the preservation of their sexual and reproductive health, with the adoption of measures to promote disease prevention.

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